The “Duty to Die” Advances

by The Center for Bioethics and Culture

By Wesley J. Smith, J.D., Special Consultant to the CBC

Is there such a thing as a “duty to die?” Some notable voices in bioethics say, yes. They believe that as a matter of distributive justice, when people reach a certain advanced age, severe disability, or very poor health, they owe it to society, their families—and even themselves—to allow life to (or make it) end.

Thus, in 1997, University of Tennessee bioethics professor, John Hardwig, wrote in the prestigious Hastings Center Report, “A duty to die is more likely when continuing to live will impose significant burdens—emotional burdens, extensive caregiving, destruction of life plans, and yes, financial hardship—on your family and loved ones. This is the fundamental insight underlying a duty to die.”

One of the United Kingdom’s leading bioethicists, Baroness Warnock, has also supported the duty to die. As reported by the UK’s Independent newspaper in 2008:

She is quite happy with the notion of the ‘duty to die’ . . . A couple of months ago, in an interview with the Church of Scotland’s magazine Life and Work, she said: “If you’re demented, you’re wasting people’s lives—your family’s lives—and you’re wasting the resources of the National Health Service.”

To date, no country has actually enacted such a legal requirement on its citizens. But that should not make us sanguine. To the contrary, a through-the-back-door duty to die has already been launched through policies that permit doctors to refuse so-called “futile” treatments.

Futile Care Theory, aka “medical futility,” has been on the bioethics movement’s agenda for more than ten years. Here’s how it works: If a patient or their family want life-sustaining treatment—generally in the ICU setting—but doctors and/or bioethicists think it is “inappropriate” based on quality of life or cost/benefit judgments, the treatment may be unilaterally withheld or withdrawn. Let’s be clear: “Futile care” treatments aren’t refused because they don’t work. To the contrary, they are denied because they keep the patient alive.

The recent Baby Joseph case in Canada provides a vivid example. Joseph was dying of a genetic disease. Joseph’s doctors, supported by hospital bioethicists and administrators, told his parents that they were going to refuse all further life support. But when the parents asked for a tracheotomy to enable them to take their son home to die, the doctors said no again. They thought it was best for Joseph to die sooner, not later.

The case went to court, but before it was adjudicated, Priests for Life found a U.S. hospital where the tracheotomy could be performed. The surgery was successful, and Joseph’s parents took him home. He lived—and was loved—for an additional seven months, time that he and his parents would have been denied had the Canadian doctors been allowed to impose their will.

Futile Care principles have now escaped the ICU with the growing trend to deny life-extending cancer treatment to terminally ill patients, often outside the hospital setting. For example, a committee of doctors in Lancet Oncology recommended rationing cancer therapies that won’t save—but could extend—terminal cancer patients’ lives. From the Daily Mail story:

Patients with terminal cancer should not be given life-extending drugs, doctors said yesterday. The treatments give false hope and are too costly for the public purse, they warned. The group of 37 cancer experts, including British specialist Karol Sikora, claimed a ‘culture of excess’ had led doctors to ‘overtreat, overdiagnose and overpromise.’

Such uncompassionate denials have already been imposed on unwilling patients in the USA. For example, Medicaid is legally rationed in Oregon. In 2008, two cancer patients were refused coverage for prescribed chemotherapy that would extend their lives for months. Showing the current trend, the state instead offered to pay for their assisted suicides. (One of the patients received the treatment free from the pharmaceutical company. The decision about the other was reversed after a public outcry.)

Coupling health care rationing and assisted suicide—a clear duty to die agenda—has been openly advocated in Vermont by a state official to the applause of an Addison County Independenteditorial:

Money must also be saved in services delivered to people with chronic diseases and those who frequently use emergency rooms, he said; two areas in which the community at large must help play an important role. Passing a law that allows physicians to help end a patient’s life under very controlled circumstances, known as “death with dignity,” is one such measure that could help (an effort was tried this past session but postponed until next year). Another is approving some type of rationing measures, as Oregon has done, that help control health care costs.

The duty to die tide is flowing, and it won’t stop with the terminally ill. When I was researching my book Culture of Death, I interviewed an advocate of medical futility and noted that refusing ICU treatment wouldn’t save a lot of money. I asked what futilitarians (as I call them) would try to cut next? He responded, “marginally beneficial care.” His example? Refusing mammograms to women above the age of 80.

Make no mistake, when medically efficacious treatment is denigrated as “futile” or “marginally beneficial,” it isn’t really the care that is being so described, it is the patients.

CBC special consultant Wesley J. Smith is a Senior Fellow in Human Exceptionalism at the Discovery Institute and a lawyer for the Patients Rights Council.